Ruminations by a non-academic general surgeon from the heart of the rust belt.

Saturday, April 5, 2008

Anal Fissure

Few maladies are as disconcerting and uncomfortable as the dreaded anal fissure. What is it? Simply a tear in the skin and mucosa of the anus. This area is highly innervated and the tear causes severe pain and often bleeding, especially with bowel movements.

Pathophysiology: Mechanical trauma which leads to sphincter spasm which leads to inability for the anoderm to heal, which leads to more sphincter spasm and pain, which leads to less healing, which leads to.... you get the idea. It's a vicious cycle that won't stop until you either control the pain or relieve the sphincter spasm.

Presentation: Horrendous, excruciating tearing sensation with BM's, often accompanied by bright red blood on the toilet paper. Patients adapt by trying to avoid the toilet, which leads to worsening comstipation and harder stools which leads to..... get it?

What the hell should I do? See your doctor. Don't screw around with expensive, useless over the counter products like Preparation H or laxatives, etc. You're just wasting time and money. 90% of anal fissures will heal on their own, without surgical intervention, but it isn't something you should self-treat. Often your PCP will refer early in the game to a surgeon.

Medical Treatment Options:
1. Sitz Baths- soothing soaks can relieve the itching and pain and relax the sphincter. Plan on sitting in a warm bath two or three times a day for twenty minutes at a time
2. Proctofoam- Some docs will rpescribe this; I haven't seen much efficacy though.
3. Nitroglycerin ointment (0.2%)- I've actually seen this work. It relaxes the internal sphincter and some studies have demonstrated healing rates of 60-80%, but the recurrence rate is rather high. Some patients develop headaches which can be quite severe. Also, patients will significant cardiac history need to be careful.
4. Diltiazem ointment (2%) - Essentially works by same mechanism. Efficacy similar to nitro.
5. Botox- Paralyzes the sphincter, but overall, outcomes are worse compared to nitro and diltiazem.
6. Stool softeners, high fiber diet- Soft and regular is the way to go. Hard pieces of coal dropping out your back end are not good for the ballclub.
7. Lidocaine jelly- I always prescribe this; seems to help.

The reason the pharmaceutical agents don't always work is that some fissures become chronic and form a triad of a deep ulcer, a sentinel pile, and a hypertrophic anal papilla. This situation often needs the attention of a surgeon

Surgical Therapy:
Defintive treatment involves doing a lateral internal sphincterotomy. This procedure will heal 97% of fissures. Often, a fissurectomy can be done at the same time, excising the chronic triad. I do these in the OR with the patient either asleep or anesthitized with a spinal block. Patient is placed in prone jack-knife position with the butt cheeks taped open. It's a cool, highly satisfying operation. I make a small incision right at the anal verge and dissect out the thickened internal anal sphincter. You can't miss it; it's like one of those Lance Armstrong Livestrong bracelets encircling your anus, deep to the skin. A quick cut and the tension in the anus almost immediately decompresses. If the fissure is nasty looking and edematous, I'll also sometimes excise the whole fissure complex as well. The case takes about five minutes usually. Relief comes a bit more slowly, hours to days (after all, the treatment does involve using knives on your ass). Sitz baths are resumed and stool softeners maintained for several weeks. Complications are rare but sometimes patients will note incontinence of flatus in the immediate post-op period. Incontinence of stool is an extremely rare and devastating complication.

26 comments:

Long time lurker, first time poster! Yes, knives around arseholes sure is painful. I should know, I've had a haemorrhoidectomy and I don't know what was worse .. putting up with grapes hanging out of my arse or getting them cut off! Five wonderful roid-free years, now ... they're baaaack!

My son had this (age 17), after falling 65 ft. onto a pipe in the straddle position. He mashed up his sacral plexus, and it was no fun to get his bowels working again. The first one made him cry like a baby--it was horrible.

Problem with lithotomy is that it's hard to get an assistant in there to help you because it's so tight. Say you need to resuture a hemorrhoid pedicle and blood is everywhere; it's MUCH easier to have the patient in prone jack knife.

Er, so why can't I recommend the sitz baths and write for the lidocaine jelly, waiting to refer only those who don't heal (the minority, as you say) to you? Oh wait: I do. Not every asshole deserves a surgeon, and vice versa. (Sorry; couldn't resist. Nice blog, btw.)

Gotta be careful with anterior ones, especially in women. Not much sphincter anteriorly and you can render a patient incontinent with an overly aggressive approach. Anterior fissures can also be seen in patients with Crohn's disease....

Hey Doc...so here's a question, I had an anal fissure about 2 1/2 years ago. I had surgery because my anus was "too tight". I believe I am starting to get another one again. Is that possible? BTW, I appreciate your since of humor, maybe you will mine too- when the Doc told me I had an anal fissure for the first time I thought he said anal fisher, all I could picture was a little man fishing down there like an icehole. My hubby said he was fishing for crappie!

So I had the sphincterotomy and it worked for about a month. Then back to the same old pain and bleeding. Then we talked with a specialist and he suggested putting a cotton ball there to draw out the moisture. Sounds weird, but it has helped me a lot, and the pain still comes and goes, but it is so much more manageable. I write this because it wasn't on any website that I ever read, so there you have it. Cotton balls. Not as uncomfortable as it seems like it would be...

Doctor, I have a fissure and have just realized the prescription was filled with Lidocaine 2% Viscous solution RX, which is actually an oral solution. Is this ok to use or do I need to take it back to the pharmacy for the gel. The pharmacy seems to think it works the same way as the form that resembles vaseline, is it really the same

I had never had fissures until after the birth of my son 15 months ago. They have not healed in all that time. I can manage them by taking Metamucil every day... but the minute I don't take it, or drink less water, or eat anything other than veges and whole wheat etc, they are back. I have never felt such pain. My question is this: I had an episiotomy.... could this have affected something in the area to cause this?

this is mu 2nd anal fisher i am 38 i have had surgery and now its back i am taking nitro-bid,lidocaine.hemorrid cream sitz bath i grip the walls please doc advice please also i saw a doctor they said nogo because i already had a sphixonotamy(?) i am also on malrlex.

hello Docter,Im 27 yrs old male and have anal fissure and its old also,i mean its been 1 year that im suffering from itching and discomfort in anal,bleeding occurs very rare(once in two month).I have tried every solution.Docters have suggested me surgery,bt im too much afraid of the consequences as i have read that 5% of the patient after surgery gets compliction.I smoke also,Does it aids the problem.and my stomach is not well all the time.All the time i feel that there is something that is causing the discomfort in stomach as well and it increases as i have TEA or CIGGRETE.Please suggest something as im just spending evry day and not enjoying my work and life.Want to see the world without the discomfort.

Is a sentinel tag (flap of skin, vs. the bumps outside the anus - have those too) near the vaginal area (anterior?) a sure sign of a fissure or not necessarily (hence maybe just a hemorrhoid or loose skin)? Can a sentinel tag, what I'm calling anterior (near perineum) heal without surgery? Is there anything (or astringent things) that can be done to assist this healing? *Finally, and most importantly, is a surgery to correct what I'm calling an anterior sentinel tag associated with the risk of (fecal?) incontinence like you said the surgery for anterior anal fissure is? Not asking for advice, but general info I can discuss with a doctor, thanks.

Have you ever had a situation where the incision spot will NOT heal after this surgery? Any suggestions? My Dr told me that I would just get used to the pain and bleeding and I probabaly would not notice it after some time??? It is just like a fissure...only man made. It is painful and it is controling my life. His answer was also that the trend would be my friend until the end. Meaning that this is about as good as it will get? I really have a hard time believing this? No other Drs will see you if you have already had surgery with some one else. I would love any opinion. It has been 5 months since my surgery.

In 2003 I experienced the pain of anal fissure, after using stool softeners, lidocaine and suppositories, I received some relief from Glyceryl trinitrate or GTN ointment.It eased the pain and seemed to cure the fissure but caused headaches almost immediately. Three years later, the problem arose again. I used every single treatment, sitz baths, Proctofoam, GTN ointment, Lidocaine gel, stool softeners, increased fiber intake and the only thing that helped was the botox injection directly into the fissure. Athough it eased the pain instantly, the bleeding continued so I opted to go through the lateral sphincterotomy procedure. It was done and I experienced one day of pain as anesthesia wore off. No problems since and that was over a year ago.

i cannot even begin to tell you how much pain i am in, and how utterly humiliating trying to treat this has been. this had been going on for more than half a year...i had one a few years ago and it wasn't painful and it went away on its own. but this was immediately painful to the point where a can barely sit, and sleep. I went to my normal doctor because the wait to see a G.I. specialist is over a month...and she prescribed me these awful suppositories that not only hurt like hell to insert but didn't help. I increased my fiber intake and i have to take mirolax daily to prevent ripping...and even that doesn't always help and the bottle says not to take for more than 7 days i am definitely over that. I tried to switch to a bulk fiber supplement but that seemed to make things thicker and that caused tearing as well... I finally made an appointment with the G.I. specialist but it is not for 3 more weeks and i am barley getting through my everyday life...i called my normal doctor back begging to try something else and she gave me even larger suppositories i cant even begin to try to insert them because of how much pain im in i am never going back to that woman....what part of my butt-hole is ripped makes putting a giant suppository up there sound like a good idea? trying to insert it causes more tearing! at this point i am just scared to death that there is permanent damage done. i am barely able to go to the bathroom...it tears almost every time and bleeds quite a bit. i have horrible itching anytime after i go to the bathroom and even a hot soak in the bath only helps while im in it...i just hope that this isn't permanent damage and that it can be healed im terrified of becoming incontinent....can these become infected? im seriously concerned and i have a few weeks before i can have someone qualified look at it. :( i am in so much pain

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